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oyuaiy.iyneabyrrancm=n. <br />Francine R. Villareal <br />bate. xoxION <br />' o.flaz lgA3:x6 os•w' <br />ACORO� CERTIFICATE OF LIABILITY INSURANCE <br />ll.. <br />DATE(MM/DD/YYYY) <br />10/21/2020 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER Patriot Risk & Insurance Services <br />2415 Campus Drive, Suite #200 <br />Irvine, CA 92612 <br />CONTACT <br />NAME: <br />PHC NE 949 486-7900 FAIX <br />c No: <br />E-MAIL <br />ADDRESS: <br />INSURERS AFFORDING COVERAGE <br />HAIG# <br />www.palrisk.com OK07568 <br />INSURERA: Middlesex Insurance Company <br />23434 <br />INSURED <br />Mike Prilch &Sons, Inc. Elton <br />5103 Elton St. <br />INSURERS: Navigators Insurance Company <br />42307 <br />INSURER C: Slate Compensation Insurance Fund <br />INSURERD: IronshoreSpecialty Insurance Co <br />25445 <br />Baldwin Park CA 91706 <br />INSURER E: Lloyds of London <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 58242193 REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDLSUBR <br />POLICY NUMBER <br />POLICY EFF <br />MWDDII^/YV <br />POLICY EXP <br />MMIDDYYYY <br />LIMITS <br />A <br />t/ <br />COMMERCIALGENERAL LIABILITY <br />CLAIMS -MADE OCCUR <br />✓ <br />✓ <br />A0152818 <br />8/1/2020 <br />8/1/2021 <br />CURRENCE <br />$1000000 <br />RENTED <br />S Ea occurrence <br />$500000 <br />✓ <br />(Any one person) <br />$10000 <br />$5,000 Deductible <br />AL & ADV INJURY <br />FGENER�I <br />$1 000 000 <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />POLICY ✓❑ PRO- <br />JECT � LOG <br />AGGREGATE <br />$3,000,000 <br />TS-COMP/OPAGG <br />$2000000 <br />$ <br />OTHER: <br />A <br />AUTOMOBILE <br />LIABILITY <br />A0152818 <br />8/1/2020 <br />8/112021 <br />COMBINED EINGLE_LIMIT <br />F. <br />$1000000 <br />Boo ILV INJU RY(Par person) <br />$ <br />ANY AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />BODILY INJURY Per eccldenl <br />( ) <br />$ <br />PROPERTY DAMAGE <br />Per accident <br />$ <br />$ <br />H <br />B <br />UMBRELLALIAB <br />✓ <br />OCCUR <br />LA20EXC7820511C <br />8/1/2020 <br />8/11 0021 <br />EACH OCCURRENCE <br />AGGREGATE <br />EXCESS LIAR <br />CLAIMS -MADE <br />DED RETENTION$ <br />C <br />WORKERS COMPENSATION <br />EMPLOYERS' LIABILITY YINOFFICRANYPROPMEMB REXCLUDEDP ECUTIVE <br />NIA <br />9280970-2020 <br />8/1/2020 <br />8/1/2021 <br />,/ STATUTE ERHAND <br />E001001 <br />E.L. EACH ACCIDENT <br />E.L. DISEASE -EA EMPLOYEIfyes, <br />(Mandatory In NH) <br />describeunderDESCRIPTION <br />E.L. DISEASE -POLICY LIMIT <br />OF OPERATIONS beow <br />D <br />Pollution Liability <br />004158101 <br />8/112020 <br />8/1/2021 <br />$2,000,000 Occur / $2,000,000 Aggregate <br />$10,000 Deductible. <br />E <br />Professional Liability <br />ELOO-98-0052-2020 <br />8/1/2020 <br />8/1/2021 <br />$1000000 Occurrence/AxIcIregate <br />DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) <br />Re: City of Santa Ana's Emergency Sewer and Water System Repair Services RFP 19-032. The City of Santa Ana, it's officers, employees, agents, <br />volunteers and representatives are named as Additional Insured as respects to General Liability as per endorsement attached as required by <br />written contract. Primary/non-contributory endt attached. <br />30-day notice of cancellation 110-days for non-payment of premium. <br />CI of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />tY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Center Plaza <br />Santa Ana CA 92702 AUTHORIZED REPRESENTATIVE �P <br />A"--fV tee. 0„a. "Ma1u%nNeMfXvjeilm <br />Dave Jacobson A±7 � REVIEWED&APPRovEDBY: <br />©1988-2015 ACORD C I s v1 ,, VZt&,W 4 <br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Risk Management:Ana(yat <br />50242193 20/21 GL/AU/W.8(WC/POLL I Tina Kennedy 1 10/21/2020 4:36:5e PM (PDT) I Page 1 of 14 <br />This cerl ificate cancels and supersedes ALL previously issued certificates. <br />